405 IAC 5-28-11 - Hyperbaric oxygen therapy
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15
Sec. 11.
(a) Medicaid
reimbursement is available for hyperbaric oxygen (HBO) therapy for the
following conditions:
(1) Acute carbon
monoxide intoxication.
(2)
Decompression illness.
(3) Gas
embolism.
(4) Gas
gangrene.
(5) Acute traumatic
peripheral ischemia.
(6) Crush
injuries and suturing of severed limbs; as in the previous conditions, HBO
therapy would be an adjunctive treatment when loss of function, limb, or life
is threatened.
(7) Meleney ulcers;
the use of hyperbaric oxygen in any other type of cutaneous ulcer is not
covered.
(8) Acute peripheral
arterial insufficiency.
(9)
Preparation and preservation of compromised skin grafts.
(10) Chronic refractory osteomyelitis,
unresponsive to conventional medical and surgical management.
(11) Osteoradionecrosis as an adjunct to
conventional treatment.
(12) Soft
tissue radionecrosis as an adjunct to conventional treatment.
(13) Cyanide poisoning.
(14) Actinomycosis, only as an adjunct to
conventional therapy when the disease process is refractory to antibiotics and
surgical treatment.
(15) Acute
cerebral edema.
(b)
Medicaid reimbursement is not available for therapy by HBO for the following
conditions or services:
(1) Topical
application of oxygen.
(2)
Cutaneous, decubitus, and stasis ulcers.
(3) Chronic peripheral vascular
insufficiency.
(4) Anaerobic
septicemia and infection other than clostridial.
(5) Skin burns (thermal).
(6) Senility.
(7) Myocardial infarction.
(8) Cardiogenic shock.
(9) Sickle cell crisis.
(10) Acute thermal and chemical pulmonary
damage, including smoke inhalation with pulmonary insufficiency.
(11) Acute or chronic cerebral vascular
insufficiency.
(12) Hepatic
necrosis.
(13) Aerobic
septicemia.
(14) Nonvascular causes
of chronic brain syndrome, including Pick's disease, Alzheimer's disease, and
Korsakoff's disease.
(15)
Tetanus.
(16) Systemic aerobic
infection.
(17) Organ
transplantation.
(18) Organ
storage.
(19) Pulmonary
emphysema.
(20) Exceptional blood
loss anemia.
(21) Multiple
sclerosis.
(22) Arthritic
diseases.
(c) Hyperbaric
oxygen therapy shall be clinically practical and shall not be a replacement for
other standard successful therapeutic measures.
Notes
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